Frequency of brain injury in a forensic psychiatric
population
Freqüência de traumatismos craniencefálicos numa população
psiquiátrica forense
Carlos Alberto Crespo de Souza
Study Center José de Barros Falcão/ Federal School of Medical Sciences of Porto Alegre Foundation. Porto Alegre, RS, Brazil
This study was performed in Forensic Psychiatric Institute ‘Dr. Maurício Cardoso’ of Porto Alegre, RS, Brazil.
Part of the Doctorate thesis ‘Underestimation of traumatic brain injuries in the assessment of a forensic psychiatric population in Rio Grande do Sul’, submitted to the Psychiatric Institute of the Federal University of Rio de Janeiro in November 2000, with modifications for its publication in the Official Journal of the Brazilian Psychiatric Association.
None financial support and conflict of interest. Received on 18/7/2002. Approved on 28/5/2003.
Objective: Over the last years, a growing number of studies involving individual patients and/or populations have demonstrated that Traumatic Brain Injuries (TBI) determine innumerable psychiatric symptoms, including significant alterations which may influence diagnoses, prognosis and treatment, not to mention clear psychosocial implications (both legal and those related to social security). The objectives of this study were 1) to detect the existence of TBI in a forensic psychiatric population before the occurrence of the wrongs; 2) To verify whether or not those injuries had been identified by the experts at the psychiatric institution.
Method: 3,323 records of patients examined by forensic experts at the Forensic Psychiatric Institute Dr. Mau-rício Cardoso in Porto Alegre were analyzed; the records covered the period between 1995 and 1999.
Results: in the studied population, there were 133 cases of TBI prior to the wrongs, 39 of which were mild, and 94, moderate or severe. Out of the total number of TBI cases found, 111 cases were not taken into account, many of them having motoric, cognitive, psychic and sensori perception alterations.
Conclusion: the significant number of patients that had had TBI before having committed a wrong - a fact that had not been considered by the experts (neurologists and psychiatrists) at the institution - is a strong indicator of how little attention is paid to the consequences of these injuries. Considering the relevance of the psychosocial aspects, new studies should be conducted in psychiatric populations to increase the knowledge about the consequences of these injuries.
Traumatic brain injury. Population research. Forensic psychiatry. Psychiatric epidemiology.
Objetivo: Cada vez mais, nos últimos anos, estudos em pacientes individuais e em populações demonstram que os traumatismos craniencefálicos (TCE) determinam inúmeros sintomas psiquiátricos, com significativas alte-rações que podem influenciar os diagnósticos, os prognósticos, os tratamentos e com evidentes implicações psicossociais, incluindo as jurídicas e previdenciárias. O objetivo deste estudo foi o de 1) Detectar numa popu-lação psiquiátrica forense a existência de TCE antes do acometimento de delitos; 2) Verificar se houve reconhe-cimento desses traumatismos por parte dos peritos da instituição.
Método: Foram analisados 3.323 prontuários de pacientes submetidos a exames periciais no Instituto Psiquiá-trico Forense “Dr. Maurício Cardoso” de Porto Alegre, entre 1995 e 1999.
Resultados: Na população estudada, foram encontrados 133 TCE ocorridos antes dos delitos, sendo 39 leves e 94 moderados e graves. Do total dos casos encontrados, não foram considerados 111 casos, muitos deles com alterações motoras, cognitivas, psíquicas e sensoperceptivas.
Conclusão: O expressivo número de pacientes que sofreu TCE antes dos delitos cometidos e que não foi con-siderado pelos peritos (neurologistas e psiquiatras) da instituição forense é forte indicativo do pouco conheci-mento das conseqüências desses traumatismos. Considerando a relevância dos aspectos psicossociais envolvi-dos, novos estudos necessitam ser realizados junto a populações psiquiátricas de maneira a aprimorar o conhe-cimento a respeito das conseqüências desses traumas.
Traumatismos craniencefálicos. Pesquisa populacional. Psiquiatria forense. Epidemiologia psiquiátrica.
Abstract
Keywords
Resumo
Introduction
As a rule, traumatic brain injuries (TBI) and especially mild ones (MTBI) have been scarcely studied regarding their psy-chiatric consequences. It was only after the denounce of Parker in the US in 1990 that MTBI started to be considered as poten-tially capable of promoting significant psychiatric alterations. In his denounce, Parker stated that the absence of this consid-eration would determine an actual silent epidemic, developing as a result from sequels (mainly cognitive and behavioral).1 Even after his denounce, only after 1995 the medical commu-nity (notoriously represented by neurologists and psychiatrists) has somehow woken up. Since then, year after year MTBI has started to be increasingly studied.2.
In 1996, Kay mentioned that careful interviews with people who later in lifetime had important emotional, interpersonal and behavioral problems had identified that they had suffered a mild TBI at some periods of their lives, and this fact was likely to be found in patients examined in psychiatric clinics or in forensic examinations.3 His expressive words were based on individual interviews and on empirical findings performed by other authors, and were connected only to mild traumatic brain injuries (MTBI).
Jorge et al4 (2000) reported that the association between brain injury and psychiatric disorders, although already registered by the medical literature for many years, has been sporadic. As an example, they mentioned the fact that in 1904 Adolf Meyer identified a number of disorders which he called traumatic in-sanities. During World War II, physicians identified a high in-cidence of psychiatric complications after brain injuries. Many of these studies emphasized the importance of frontal lesions in the pathogenesis of behavioral disorders.4
These authors recognize that the majority of such disorders has not been examined in their extension, be it on individual patients, be it in a population of patients with TBI. They high-light that studies about the interface between TBI and psychia-try in populations has been, until recently, rare or inexistent, but acquire a significant psychosocial importance.Ibid
However, already since that same year and in the three sub-sequent years of the new decade, studies about this interface have started to be accomplished, encompassing greater or smaller populations, distinct objectives, research instruments and at different times after the TBI. Populations with the most varied ages were examined in mental health ambulatories, in psychiatric hospitals, in recovery programs after the TBI, etc. The association between TBI and psychiatric disorders, have started to be investigated, in an unequivocal demonstration of the concern with this interface, a product of the new knowl-edge which recognized their relevance.
Most of the recent studies also point out that the prevalence of TBI among psychiatric patients is unknown and that investiga-tions in the general population are rare. Existent studies found that children and adolescents who had TBI are more likely to develop anxiety disorders (generalized anxiety, obsessive-com-pulsive symptoms, separation anxiety and simples phobias),5 oppositional, conduct and attention-deficit with hyperactivity disorders, besides a higher trend to develop alcohol or substance
dependences.6 Among hospitalized or ambulatory psychiatric populations there has been a higher number of TBI than among control groups, with predominance of depressions and panic episodes.7,8 A higher vulnerability to the development of psychi-atric disorders after TBI,9 the need of psychosocial support for these patients,10 bipolar disorders and history of sexual abuse,11 secondary personality disorders and sexual transgressions,12,13 increase of rehospitalizations due to epilepsy and psychiatric disorders among patients who had TBI,14 patients with post-trau-matic epilepsy and anti-social attitudes,15 psychotic syndromes and a higher number of TBI among schizophrenic patients.16,17 Other studies reported that patients with Organic Personality Disorder after a TBI had higher difficulties in psychosocial ad-justment and more emotional problems than patients with TBI without diagnosis of Organic Personality Disorder.18 Other re-cent study found a close relationship between subjects with genes related to schizophrenia and previous TBI and their being more likely to develop the disorder.19
Although preliminary and subject to new studies, these re-searches have identified significant psychiatric alterations af-ter the severe, moderate and mild TBI. In the same way, they show that these alterations can be transitory, moderate or re-main along the lifetime of patients who TBI. They also register that electroencephalographic (EEG) and neuroimage studies, such as computer tomography (CT) and magnetic resonance (MR) - which are currently used in large scale in emergency services and neurological clinics in Western countries -, are most of times incapable of diagnosing a mild brain injury -characteristically represented by subtile alterations, by chemi-cal and electrichemi-cal modifications and not detected by CT or MR, creating significant secondary symptoms due to the dilemma of returning to school or to the job in the presence of incapaci-tating symptoms or impairing alterations.
Considering all these findings, in our study we decided to verify the number of TBI before the wrongs and whether these traumas were taken into account by experts (neurologists and psychiatrists), responsible for examinations of criminal liabil-ity in a Brazilian forensic institution.
Methods
Design
distinguish-ing the degrees. On the other hand, referrdistinguish-ing to mild TBI, they reported to ‘TBI without loss of conscience’ or ‘with rapid loss of conscience’ and without hospitalization or with a brief pe-riod of hospitalization, without sequels.
Regarding recoveries, data remained purposely open, and there were no parameters established by neurologists and the research attempted to know how neurologists or psychiatrists assessed patients.
Besides, the items ‘personal morbid antecedents’, ‘psychiat-ric observation’, ‘diagnostic discussion’ and ‘positive diagno-sis’, that are part of the ‘standard expert report’, were exam-ined to verify if expert witness psychiatrists had reported or not the TBI in those topics (having in their hands, obviously, the result of the neurological exams which are included in the Diagnostic Discussion).
In the cases in which psychiatrists had requested a psychodi-agnostic assessment, due to a hypothesis of ‘organic’ impair-ment, it would be also examined and verified whether or not their results were taken into account by expert psychiatrists, provided they were related to TBI.
Site
The study was performed in the Forensic Psychiatric Institu-tion ‘Dr. Maurício Cardoso’ (IPFMC) of Porto Alegre, state of Rio Grande do Sul, Brazil, an institution which receives pa-tients from all Criminal Circuits of the state.
Participants
Medical records of all patients who had been subjected to psychiatric assessment in the institution were analyzed. The time period of the assessments was randomly chosen, between the years 1995 to 1999. Although the period was random, two issues influence this choice: first, the fact that the new contri-butions about TBI had been expanded since 1995 (the degree of awareness of technicians about the issue was not known) and second, due to the fact that this period, besides having a significant sample of 4,500 to 5,000 records, would correspond to the last years (if a study were performed before 1995 it would be hindered, as TBI and their psychiatric repercussions were totally unknown in Brazil at that time).
Results
When we examined the records, we noted that the initial es-timated number would not be achieved. We observed then that the Institution had different criteria to register its data: the Tech-nical Department used to include in its statistics the total of performed procedures, regardless to how many examinations or exams the same patients were submitted (some of them with three or more assessments in the same or subsequent annual period).On the contrary, the Archives Department, recorded only the new patients, not taking into consideration the reen-tries for further assessments.
Considering that in the reentries patients had inevitably their historical data and diagnoses only revalidated, we un-derstood that the statistics of this sector would be the cho-sen one (new patients).
Therefore, according to the Institution’s official data, pro-vided by the Archives Department, in the year 1995 there were records from number 10,432 to 11,047, totaling 615 records. In 1996 the number of records would reach to 590, numbered from 11,048 to 11,638. In 1997 there would be 593 records, ranging from numbers 11,639 to 12,232. In 1998 there would be 795 records, between numbers 12,233 and 13,028 and, lastly, in the year 1999 there would be 950 records from numbers 13,029 and 13,979. The total of records, according to the offi-cial registers provided by this sector would reach 3,543.
However, when carefully examined, we noted the absence of several numbers, the sequences being interrupted innumer-able times such as skipping from number 12,331 to number 12,333. Sometimes, we found records of different patients with the same number (few cases) and unnumbered records (few cases).
Obviously, due to the absences, out of the established and official total we found and examined 3,323 records. Out of this total, 503 records were excluded due to the lack of data (ab-sence of psychiatric assessment, assessments which had been suspended due to any bureaucratic or legal reasons, patients who had come from prisons only due to the Supervenience of a Mental Disease for psychiatric treatment, others who had de-ceased during the slow legal procedures, etc.). Therefore, sub-tracting 503 records from the examined total, we included a total of 2,820 records that were analyzed according to the study’s presuppositions.
According to the distribution of yearly occurrences of TBI, among the 2,820 records, which had occurred any time before the wrongs and regardless gender, race, origin and schooling of patients (the age corresponded to the limits of patients who are, usually, examined in the IPFMC, i.e., from 18 years old onwards) we found 15 cases in 1995, 25 in 1996, 31 in 1997, 34 in 1998 and 28 in 1999, totaling 133 cases.
Out of the existent TBI before the wrongs (133), 39 were diagnosed as mild and 94 as severe or moderate. The distribu-tion of TBI occurrences according to the result of neurological exams evidenced that 105 were diagnosed as normal, 20 had pathological results, 7 had diagnosis of post-traumatic epilepsy and 1 had mental impairment.
The diagnose of the 105 subjects considered as normal by neurologists were based on the clinical neurological exams and in the EEG. The 20 subjects with a pathological diagnosis, added to the 8 with post-traumatic epilepsy and mental impairment, had pathological neurological exams which included the clini-cal exam, EEG, Brain X-rays and CT. From these total, 9 CT and no MR were requested.
Out of 9 CT requested by neurologists, in three of the pa-tients there were, immediately after the injury, pathological results (parenchyma alterations) and at the expert neurological assessment, some time after the injury (months or years), they were normal.
According to the type of alteration, out of the total of TBI (133), there were 34 physical, 8 psychical and 7 mixed alter-ations and 84 without alteralter-ations (without records).
• Physical alterations: loss of audition, loss of sight, convulsive crises, most diverse neurological sequels, worsening of a previous neurological condition, temporo-spatial disorientation, loss of conscience (faintings or falls), divergent strabismus and motoric difficulty to move parts of the body.
• Psychical alterations: depression, irritability, altered conduct or behavior, worsening of a previous psychiatric condition, disorientation, impulsiveness and aggressiveness, hallucinations, delusional ideas and memory impairment.
• Mixed alterations: with symptoms that included a combination of the previously-mentioned symptoms. In the remaining 84 subjects there was no specification (record) regarding the presented symptomatology, if there was any.
From the total of TBI cases, expert psychiatrists only took into account 14.
Among all assessed cases, expert psychiatrists requested 4 (four) psychodiagnostic assessments in order to solve diagnostic doubts. One of these four assessments established a causal re-lationship between the TBI and the deficits presented by the patient, although the result was disconsidered. The other three assessments did not identify related impairments.
Two of the TBI cases had not even been submitted to neuro-logical exams and the expert reports were emitted without them. One patient had two TBI in distinct moments of his/her life and, due to the fact of having normal clinical-neurological ex-ams and EEG, was not taken into account.
Comments
The survey evidenced, in a studied population of 2,820 records of examined patients of the IPFMC for the performing of legal examinations between the years 1995 and 1999, the existence of 133 cases of traumatic brain injuries of any de-gree. This total represented 4.71% of the studied universe, a quite higher rate than that found in the general population.
Out of the 133 cases of TBI, 94 were severe and 39 mild. Considering the assessments performed by neurologists, even though a number of patients had significant neurological defi-cits (34), others had psychical alterations (8) and still others had mixed alterations (7), most of examined subjects (105) was understood as having ‘normal neurological exams’. The grounds for this diagnosis was supported only by the clinical neuro-logical assessment and the EEG.
On the other hand, of note, only 28 of the patients were un-derstood by neurologists as having neurological disorders in-cluding, as a diagnostic basis, the clinical neurological assess-ment, EEG, x-rays and CT. Also of note, only 9 brain tomogra-phies had been requested for the diagnostic elucidation of these 28 cases. This fact demonstrated an excessive confidence in the clinical assessment, in EEG and in X-rays as capable of detecting the neurological alterations that occur in the TBI or an attitude stemming from the limits imposed by the financial problems of the institution or a fact which illustrated the diffi-culties of recognizing the clinical consequences of these inju-ries and how the laboratory exams can be unable of identifying any existent alterations.
Also of note, out of the 9 CT requested by neurologists, three showed, just after the trauma, pathological results (parenchyma alterations) and, at the time of the expert neurological exami-nation, after several months or years after the injury, they were normal. Could this finding or evolution in the CT images be considered as brain recovery with the subsequent statement that these patients are neurologically normal? As verified in the studies, the answer is no; the normality of neuroimage ex-ams does not imply a clinical symptomatic recovery, as sig-nificant manifestations of impairment could still be present and determining important psychopathological and/or psychosocial consequences.
Comparing the assessment performed by expert psychiatrists with that of neurologists, we found that the number of TBI re-jected by the former reached to 111, while the latter found 105 with normal exams. Based on this fact we can infer that most of examinations accomplished by expert psychiatrists had been di-rectly influenced by the assessments performed by neurologists. This inference can be confirmed in the inverted sense: no case of TBI was diagnosed by expert-psychiatrists when neurological exams were normal. At the same time, we may say that expert psychiatrists had not taken into consideration 6 cases pointed out by neurologists as having physical, psychical or mixed symp-toms, what may be interpreted as a discrepancy.
Another verification can be made observing the data: ten cases identified by neurologists as having sequels of TBI had been ignored by expert psychiatrists in their respective ex-pert reports. We may think that neurologists only recorded physical symptoms and EEG results, without reference to any psychical impairment. However, observing that two patients with TBI (recorded in their history) were not submitted to the neurological exams and even then psychiatric expert reports were emitted, we may think that expert psychiatrists had given little attention to neurological exams. While normal, these exams would apparently help to rule out any existent neu-ronal impairment, although possibly in a bureaucratic and not technical or scientific way, as few of them acknowledged the possibility that TBI could also generate cognitive, percep-tive, psychical or behavioral impairments besides physical ones. This is well exemplified by the fact that 61 patients had significant neurological, psychical, behavioral or mixed al-terations, while 28 were so considered by neurologists and 18 by expert psychiatrists.
We may mention that out of the 28 cases which were taken into account by neurologists and out of the 18 by expert psy-chiatrists, there were 7 cases of ‘post-traumatic epilepsy’ and one case of ‘mental impairment’, which are well-established diagnoses, although without the acknowledgement that they may be part of a wider diagnosis, with other implications, due to TBI.
per-forming of their functions. Neurologists perform the neuro-logical exam, request exams regarding their field, such as EEG, x-rays, CT, etc. Psychiatrists perform the psychiatric assess-ment, request neuropsychological tests and compile all infor-mation in order to formulate the definitive diagnosis. More generally, psychiatrists base their diagnostic formulations on dynamic understandings, more concerned in determining the psychological roots of wrongs, with scarce or limited opening to the understanding of the human behavior as a whole, mainly when the brain is impaired by injury.
It was noteworthy the fact that most of found TBI were se-vere and moderate. At the same time, it is interesting how some of the patients who had had these injuries had obtained an ap-parently complete recovery along time, according to the diag-nostic criteria employed by neurologists in charge of expert examinations. However, we might ask: had they really had a complete recovery? Can the clinical neurological exam and the EEG confirm this recovery? Out of 133 cases, 105 had their exams deemed normal by means of these simple assessments, even though some of these patients had previous pathological results in their neuroradiological exams.
If in mild TBI the consequences in terms of impairment can-not be verified by the currently-employed neurological exams, could the same phenomenon occur with moderate and severe TBI some time after the injury? Could cognitive alterations, which are not detected by these exams, be present and causing impairment in several areas of impaired subjects? Could the epidemic denounced by Parker regarding the consequences of mild TBI be expanded, including the consequences of moder-ate and severe TBI?
Regarding the conduct of psychiatrists, it is noteworthy that only 4 neuropsychological assessments had been requested among 133 patients with TBI. Even when the result of one of these assessments had been positive - establishing the causal relationship between the presented symptoms and the TBI -their results were not taken into account. In a different way, these data confirm what has been already mentioned: the scarce concern of the institution’s neurologists and expert psychia-trists with the consequences of the TBI, be them arising from severe or moderate and mild injuries. Such lack of concern can be based, certainly, on the ignorance of the consequences of these injuries on people who endure them or to survivors, a fact that does not deprive of merit the institution or its techni-cians, as the recognition of these lesions has occurred only in the last years, mainly after 1995, when they started to be iden-tified and valued in the literature, whereas the most recent di-agnostic classifications, such as the DSM-IV and the ICD-10, have scarcely contributed to these recognition.
Also of note, in our study patients with MTBI were not to-tally taken into account both by neurologists and expert psy-chiatrists, as if their illness had not any psychopathological or psychosocial consequences. This lack of recognition demon-strates that MTBI and their effects or consequences are not identified, do not promote neither concern nor even consider-ation by the physicians of the Forensic Institution of Porto Alegre, what does not differ, possibly, from the other Western
physicians, who are used to hermetic divisions between the physical and the psychical, besides knowing quite little about the consequences of TBI on the psychism and behavior.
Conclusion
Our study allowed to verify that mild TBI is not deemed determinant of neuropsychiatric sequels both by expert neu-rologists and psychiatrists. The most significant fact is that mod-erate and severe TBI, according to normal exams at the exami-nations - after some time from the injury - caused lack of aware-ness on experts. Many of these patients still had significant neurological, psychical and mixed alterations, surprising their not being taken into account.
The study shows the abysm that exists in the interface be-tween the TBI and neurology and psychiatry in the studied popu-lation, especially in the consequences on the practice of clini-cians and experts. This finding does not differ from other ser-vices, possibly due to the dichotomy between the organic and the psychic, which prevails in Western medicine. Besides, other similar or more systematized researches should be performed to replicate our findings, although there are many studies, as already mentioned, that had already evidenced the severe neu-ropsychiatric implications in several distinct populations.
Complementing these conclusions we must remind the im-plications of the absence of a correct diagnosis, both for clini-cians and experts (social security or forensic), that may repre-sent to subjects who had TBI and who had their sequels not taken into account.
Until few time ago, the importance of TBI in the genesis of many cognitive or behavioral difficulties, understood as psy-chic or psychiatric, was ignored. However, the current state of knowledge demonstrates the opposite. According to Hyman, with this new knowledge, up to now deeply-rooted concep-tions may be replaced and promote new approaches to the in-terpretation of neuropsychological profiles of patients who had TBI, providing better assessment and, consequently, treatment and follow-up.20
This study was the first in Brazil and Latin America who dealt with this theme. Although the results, as a rule, are in accordance with population studies regarding the scarce con-sideration given to the consequences of TBI in the production of psychiatric manifestations, there is no similar study in the literature. It is necessary to consider that existent studies with populations impaired by TBI have started only few years ago and are, due to that, very recent. There are almost no identical studies, with different objectives and methodologies, assess-ing distinct populations and in varied periods.
References
1 Parker R. Traumatic brain injury and neuropsychological impairment: sensorimotor, cognitive, emotional, and adaptive problems of children and adults. New York/Berlin/Heidelberg/London/Paris/Tokyo/Hong Kong: Springer- Verlag; 1990.
2. Crespo de Souza CA. Subestimação dos traumatismos craniencefálicos na avaliação de uma população psiquiátrica forense no RGS [Tese]. Rio de Janeiro: Instituto de Psiquiatria da Universidade Federal do Rio de Ja-neiro; 2000.
3. Kay T. Minor head injury: an introduction for professionals. National Head Injury Foundation, USA. Brain Injury Information Website, 1996;(14 screens). Available from URL: http://www.bianc.org/html/tkayhdi.html 4. Jorge RE, Max JE, Robinson RG. Neuropsychiatric aspects of traumatic
brain injury. In: Saddock B, Saddock V, editors. Kaplan and Saddock Comprehensive Textbook of Psychiatry. Vol I. Chapter 2. Neuropsychiatry and Behavioral Neurology. Baltimore: Williams & Wilkins; 2000. p. 273-85.
5. Vasa RA, Gerring JP, Grados M, Slomine B, Christensen JR, Rising W, et al. Anxiety after severe pediatric closed head injury. J Am Acad Child Adolesc Psychiatry 2002;41:148-56.
6. Max JE, Koele SL, Smith WL, Sato Y, Lindgren SD, Robin DA, et al. Psychiatric disorders in children and adolescents after severe traumatic brain injury: a controlled study. J Am Acad Child Adolesc Psychiatry 1998;37:832-40.
7. McGuire LM, Burright RG, Williams R, Donovick PJ. Prevalence of traumatic brain injury in psychiatric and non-psychiatry subjects. Brain Inj 1998;12:207-14.
8. Holsinger T, Steffens D, Phillips C, Helms M, Havlik R, Breitner J, et al. Head injury in early adulthood and the lifetime risk of depression. Arch Gen Psychiatry 2002;59:17-22.
9. Shoumitro D, Lyons I, Koutzoukis C, Ali I, McCarthhy G. Rate of psychiatric illness one year after traumatic brain injury. Am J Psychiatry 1999;156:374-8.
10. Parker R. The spectrum of emotional distress and personality changes after minor head injury incurred in a motor vehicle accident. Brain Inj 1996;10:287-302.
11. Del Bello MP, Soutullo CA, Zimmerman ME, Sax KW, Williams JR, McElrroy SL, et al. Traumatic brain injury in individuals convicted of sexual of with and without bipolar disorder. Psychiatry Res 1999;89:281-6.
12. Max JE, Lindgren SD, Knutson C, Pearson CS, Ihrig D, Welborn A. Child and adolescent traumatic brain injury: correlates of disruptive behaviour disorders. Brain Inj 1998;12:41-52.
13. Tsai SJ, Hsiao YH. Secondary personality change in psychiatric in-patients. Psychiatry Clin Neurosci 1999;53:433-5.
14. Cifu DX, Kreutzer JS, Marwitz JH. Etiology and incidence of rehospitalization after traumatic brain injury: a multicenter analysis. Arch Phys Med Rehabil 1999;80:85-90.
15. Semenov VG. The forensic psychiatric expertise of patients with epilepsy of traumatic origin and moderately pronounced mental disorders. Lik Sprava 1999;12:106-9.
16. Daryl E, Fujii D, Ahmed I. Risk factors in psychosis secondary to traumatic brain injury. J Neuropsychiatry Clin Neurosci 2001;13:61-9.
17. McAllister TW. Traumatic brain injury and psychosis: what is the connection? Semin Clin Neuropsychiatry 1998;3:211-23.
18. Damasio A, Tranel D, Damasio H. Individuals with sociopathic behavior caused by frontal damage fail to respond autonomically to social stimuli. Behav Brain Res 1999;41:81-94.
19. Malaspina D, Goetz RR, Harkavy. Traumatic brain injury and schizophrenia in members of schizophrenia and bipolar disorder pedigrees. Am J Psychiatry 2001;158:440-6.
20. Hyman SE. The millennium of mind, brain, and behavior. Arch Gen Psychiatry 2000;7:88-9.
Correspondence:
